1. QI: No News May Not Be Good News
Lisa Cabrera
Katherine Ko
Kathryn Pugh
Stephanie Wizel
March 18, 2015

2. Background Patient 10-year-old female History of asthma
15 lb weight loss in 3 months
No changes in diet or urination habits
Thursday: physical exam was unremarkable & basic labs were ordered
Kat

3. The Problem
Labs were drawn on Thursday, when the patient visited the pediatrician
Blood glucose was 320 mg/dL
This critical lab result was not received until patient’s mother called office on Monday to follow- up with the lab results herself
Repeat test on Monday: BG 450 mg/dL
UA on Monday also showed moderate ketones
Kat

4. Red Flags Rapid weight loss in patient--no concerns raised
Primary MD leaves for weekend without delegating lab result auditing and follow-up duties to covering MD
Critical lab result is faxed over but overlooked by covering MD
Primary physician fails to audit lab results received during his absence and therefore fails to inform patient of critical lab result (BG 320).
Kat

5. Fishbone KK

6. Root Cause Analysis
A patient’s critical blood glucose lab result was overlooked. Why?
Primary physician did not delegate task to covering physician, therefore the critical lab result was not reviewed or followed up. Why?
Primary physician had no structured protocol in place for auditing and following-up on critical lab results in general, or in his absence. Why?
Office does not use an EMR system, which would have alerted the primary and covering physicians that a new critical lab result was received. Why?
Primary physician prefers to use paper charting and to review all lab results himself. KK

7. Problem:
KK (no content)

8. PDSA: Aim What are we trying to accomplish?
Prevent delayed medical treatment, due to inadequate follow-up of abnormal/critical lab results. KK

9. PDSA: What changes can we make that will result in improvement?
System Change: Implement EMR system with abnormal and critical lab result triage alerting software.
Workflow Change: Delegate daily lab result auditing and follow-up to a medical assistant.
Lisa

10. System Change: EMR & Software
Tasks
Person Responsible
When
Where
Implement an electronic medical record (EMR) system with mobile computers in all examination rooms.
Head of IT department for office
Within one month
Office/ exam rooms
Install triage alerting software with automated alerts for abnormal/critical lab results.
Office /
exam rooms
Lab results will be categorized according to degree of severity:
mild, moderate, severe, and critical.
Office/
Electronic alerts will display the patient’s current lab trends, medications, and adverse reactions and interactions.
Lisa

11. Workflow Change: Delegation
Tasks
Person Responsible
When
Where
Delegate daily lab result auditing and follow-up to medical assistant.
Office Manager
Within one month
Office
All severe and critical lab results will be followed-up by medical assistant and communicated to the physician before lunch break.
Medical Assistant
Within two
weeks
All mild and moderate lab results will be followed-up by medical assistant and communicated to the physician before clocking out each day.
Lisa

12. Predictions & Measurement
(for EMR/software & clinical workflow)
Measures to determine if prediction succeeds
EMR and triage software use errors will be less than 10% after one month.
Staff is able to navigate EMR and triage software successfully with less than 10% error rate, within one month.
Delegation of daily lab result auditing and follow-up to medical assistants will reduce lab result errors to less than 5% within one month.
Reduction of lab result follow-up errors will be less than 5% within one month of implementation.
Lisa

13. PDSA: DO EMR system will be implemented throughout the office.
EMR system will include lab result triage software for abnormal results; each result will then be triaged and categorized as: mild, moderate, severe, or critical.
Training sessions will be provided for all key employees on the EMR system and lab result triage software.
All severe and critical lab results will be followed up by medical assistant and communicated to the physician before lunch break.
All mild and moderate lab results will be followed up by medical assistant and communicated to the physician before clocking out each day.
Steph

14. PDSA: Study
Prediction
Outcome
EMR and triage software use errors will be less than 10% after one month.
EMR use error rate after one month was 9%.
Delegation of daily lab result auditing and follow-up to medical assistants will reduce lab result errors to less than 5% within one month.
Follow-up error rate after one month was 14%.
Steph

15. PDSA: Study Problem Solution
Follow-up error rate after one month was 14% due to medical assistants’ experiencing alert fatigue.
Divide daily lab result auditing, and follow-up duties, between two medical assistants in order to reduce alert fatigue.
One medical assistant will be responsible for AM results (severe and critical) and the other for PM results (mild and moderate).
Steph → MAKE SURE TO EXPLAIN ALERT FATIGUE! → 1 med assisstants fatigue (now 2 ppl, 2 shifts, two split burden/load)
reason missing follow-up = getting too many alerts now, so ...
To eliminate “alert fatigue” in physicians, delegation to a medical assistants, AM & PM, of lab auditing and follow up of test results. Medical assistant will give a report of abnormal lab values to physician.
Summary of Findings:
After one month, the largest problem was the follow-up error rate of the medical assistants due to alert fatigue.
After one month of monitoring EMR system and software use errors and retention rates, it was found that full comprehension of the technology still lacked → more training/continuous education needed

16. PDSA: Act Recommended Changes:
All ambulatory medical offices currently relying on paper charting and communication, should transition to automated electronic charting and alerting systems, in order to reduce auditing and follow-up errors.
In order to decrease incidence of alert fatigue, daily lab result auditing and follow-up duties should be divided between at least two relevant medical personnel.
Kat

17. Stakeholder Analysis Internal Stakeholders Physicians Office Manager
Medical Assistants & Staff
External Stakeholders
Patients
Family
Community
Kat

18. Force Field Analysis Forces FOR Change (Driving Forces)
Forces AGAINST Change
(Resisting Forces)
Physicians resistant to change involving technology
Dangerous outcomes due
to inadequate follow-up of laboratory results
EMRs have a proven track record at improving laboratory test
result follow-up
Lisa
After implementation, critical labs will still be missed, due M.A.’s alert fatigue.

19. Questions?

20. References
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. (2011). Agency for Healthcare Research and Quality. Rockville, MD: AHRQ Publication No
Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 20th Century. Washington, DC: National Academies Press.
Edelman D. (2002). Outpatient diagnostic errors: Unrecognized hyperglycemia. Eff Clin Pract 5(1),
Gandhi T.K., Kachalia A., Thomas E.J., et al. (2006). Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med 145(1),
Hickner J., Graham D.G., Elder N.C., et al. (2008). Testing process errors and their harms and consequences reported from family medicine practices: A study of the American Academy of Family Physicians National Research Network. Qual Saf Health Care 17(1),
Hysong S.J., Sawhney M.K., Wilson L., et al. (2011). Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak 11(1), 22.
Lin J.J., Dunn A., Moore C. (2006). Follow-up of outpatient test results: A survey of house-staff practices and perceptions. Am J Med Qual 21(1),
Lin J.J., Moore C. (2011). Impact of an electronic health record on follow-up time for markedly elevated serum potassium results. Am J Med Qual 26(1),
Matheny M.E., Gandhi T.K., Orav E.J., et al. (2007). Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med 167(1),
Moore C., Lin J., McGinn T., Halm E. (2007). Factors associated with time to follow-up of severe hyperkalemia in the ambulatory setting. Am J Med Qual 22(1),
Moore C., Lin J., O'Connor N., Halm E.A. (2006). Follow-up of markedly elevated serum potassium results in the ambulatory setting: Implications for patient safety. Am J Med Qual 21(1),
Moore C., Saigh O., Trikha A., Lin J.J.(2008). Timely follow-up of abnormal outpatient test results: Perceived barriers and impact on patient safety. Journal of Patient Safety 4(1),
Patient-Centered Medical Home. (2011). National Committee of Quality Assurance (NCQA).
Plews-Ogan M.L., Nadkarni M.M., Forren S., et al. (2004). Patient safety in the ambulatory setting: A clinician-based approach. J Gen Intern Med 19(1),
Poon E.G., Gandhi T.K., Sequist T.D., Murff H.J., Karson A.S., Bates D.W. (2004). "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern Med 164(1),
Poon E.G., Wang S.J., Gandhi T.K., Bates D.W., Kuperman G.J. (2003). Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform 36(1),
Reason J. (1990). Human Error. Cambridge, UK: Cambridge University Press.
Schiff G.D., Kim S., Krosnjar N., et al. (2005). Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. Arch Intern Med 165(1),
Wahls T. (2007). Diagnostic errors and abnormal diagnostic tests lost to follow-up: A source of needless waste and delay to treatment. J Ambul Care Manage 30(1),
Wahls T., Cram P.M. (2007). The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC
Family Practice 8(1), 32.